Discharge time must be documented in the patient's record to qualify for a discharge time greater than 30 minutes.

Discharge time must be documented in the patient's record to qualify for a discharge time greater than 30 minutes.

• A. Yes
• B. No
• C. Only if patient is admitted more than 24 hours
• D. Time documentation is optional

Answer: (A)

Discharge day management codes are time-based, and the longer code is reserved for when the time spent on the day of discharge exceeds a set threshold (about 30 minutes). Therefore, you must document the actual discharge time in the chart to justify billing more than 30 minutes. The record should reflect the total minutes spent on discharge activities, including counseling the patient and family, final instructions, prescribing or arranging follow-up, and preparing the discharge summary. Without documenting the time, you can’t support using the longer code and would default to the shorter discharge code.

Discharge day management codes are time-based, and the longer code is reserved for when the time spent on the day of discharge exceeds a set threshold (about 30 minutes). Therefore, you must document the actual discharge time in the chart to justify billing more than 30 minutes. The record should reflect the total minutes spent on discharge activities, including counseling the patient and family, final instructions, prescribing or arranging follow-up, and preparing the discharge summary. Without documenting the time, you can’t support using the longer code and would default to the shorter discharge code.